It seems a really important question to answer: “Why trust and not engagement?” We at Entrusted Consulting (www.entrustedconsulting.com) believe in reframing the way we work together and are often asked this question.

Turning to a wonderfully written report from the CIPD (Where has all the trust gone. March 2012), I would like to share an extract on why trust is so important in business and our personal lives, now more than ever.

This has been a central question from practitioners, yet conceptually trust is quite a different construct from engagement. Emerging as it has from the positive psychology movement, the term ‘engagement’ has become for practitioners an umbrella concept for capturing the various means by which employers can elicit additional or discretionary effort from employees – a willingness on the part of staff to work beyond contract. Different employers apply different outcome measures to demonstrate its efficacy as a management activity (Vance 2006; Macey and Schneider 2008). Engagement is about giving of one’s energy to an organisation, whether that is on a cognitive, emotional or physical basis (Kahn 1990), almost like an exchange relationship.

On the other hand, trust is about accepting a certain amount of uncertainty but being willing to trust the other party that they will act in a positive way towards you. Trust is about a willingness to make oneself vulnerable in the face of uncertainty or insecurity. Trust is a more personal relationship based on a perception of mutual and reciprocal aims and purpose. It is part of employee engagement, as the MacLeod Task Force ‘Engaging for Success’ acknowledges, but it is a distinct concept in its own right (MacLeod and Clarke 2009).

One simple way of thinking about the difference between trust and engagement is by comparing it with the relationship of marriage. Some days marriage partners can really love each other and some days love each other a bit less. Love is a little like engagement. It is an energy which can have fluctuating levels but for most marriages to work over the longer term each partner needs to trust the other to always have a benevolent and positive disposition towards the family, their home and their relationship. Very often when one party has an affair within a marriage it is often possible for the aggrieved party to love them again but they will report trust is more challenging to repair. Trust, therefore, can be seen as the basis by which people together create sustainable long-term relationships which see them through difficult or uncertain times.

The importance of trust at times of uncertainty is perhaps why we are more aware of it as a concept right now. People are feeling more uncertainty at a societal level and, in some cases, in the workplace. Those organisations which can maintain good trust relations or repair trust relationships will reap the business and operational benefits of trust, of which there are many. One distinct benefit of trust is its link to innovation. Some economic commentators argue that for UK plc to return to growth, restore job opportunities and find ways in which to deliver public services with reduced funding provision, innovative approaches will be key to these three activities within the workplace.

Another reason why a focus on trust is more relevant at the moment is that trust has a moral dimension to it. Engagement does not necessarily carry a moral dimension. In contrast trust does concern a firm’s moral and ethical principles (Becker 1998, Mayer et al 1995, Schoorman et al 1996). Perceptions of trustworthiness include the organisation’s competence (or ability) and predictability (Dietz and Den Hartog 2006), but also focus attention on two ethical dimensions (Searle [forthcoming]). One is benevolence, which emphasises the positive intent towards those who are trusting in them. Another is the integrity of the organisation, which concerns the degree to which they and their managers adhere to general moral standards. Research both conceptually and empirically illustrates that employees prefer to trust organisations that uphold moral and ethical standards (Gillespie and Dietz 2009, Searle et al 2011a).

As you know, I’m keen to explore further Trust and what lies behind achieving this mercurial ‘faith’ in your abilities as a leader. Please do share your thoughts on the subject – I am sure we can all learn something from each other.

A recent article by Sarah Amani, Senior Program Manager at Oxford Academic Health Science Network, beautifully distils a view on what makes for a good leader.

Sarah says; After surviving the milestone of working 10 years in the NHS, I thought I would reflect back on one of the most pivotal factors that has influenced my overall experience: Leadership. I approached the selection of this topic with some caution – I am sure most people are probably sick to death of trendy topics like leadership and the various psychosocial theories that have come out over the years. So I thought I would try to approach the topic from a slightly different angle by looking at the chemistry of leadership (bear with me here).

How Leaders are Made

There has always been a debate about whether good leaders are born or made. In a recent video by Simon Sinek titled ‘Why Leaders Eat Last’, he makes a compelling argument that good leaders are made, not born. In a compelling 45 minute video, he lays out some of the biology underpinning great leadership:

A leader is nothing to do with rank.

Leadership is a choice.

Anyone who puts their self interest aside to protect the people next to them and improve things around them is a leader.

It is therefore important to note that not all people in authority are leaders. Some are there entirely to look out for no one else but themselves. This is not leadership.

So what is it that drives good leadership? Well apparently its more scientific that I thought. Bear with me as I try to explain:

Dopamine - Be Happy

This is the reward chemical which makes us feel good from crossing off tasks as achievements. We feel good when we cross off set goals and plans because our brains release dopamine. This mechanism is used in business and industry to motivate performance via targets. It feels good to get 100% achievement against targets and the buzz from this achievement makes us want to do it again and again to get that same buzz.

However, dopamine comes with a warning as it can be highly addictive. This would explain why the banking crisis occurred – like with all addictions the rewards for achieving targets overshadowed everything else. Bankers were willing to sacrifice everything and everyone to get that next dopamine rush from reaching targets. I can’t help but wonder what implications this has on the use of targets in our healthcare system.

Serotonin - Winning Feels Good

Moving on to another chemical and one which is coined THE leadership chemical: Serotonin is said to be responsible for feelings of pride and status. It is why public recognition makes us feel good. All those awards and public acknowledgements of achievement release Serotonin. This explains why an e-mail with a certificate attachment saying ‘Well Done’ doesn’t have quite the same effect as standing in front of your loved ones, peers and team as you are given an award.

The interesting thing about how Serotonin works in this situation is that at the same time that you get a rush of that Serotonin and fill up with confidence, your peers/boss/team also get a rush of that Serotonin and share your sense of pride for being part of that achievement. This strengthens connections, raises confidence and status but also sets into motion a cycle where we want to repeat that feeling of pride and achievement. So we seek other opportunities to get other awards – to get another rush of Serotonin. This might explain the multi award winning streaks we see with some individuals and teams…

However, the expectations laid out by the actions of Serotonin can also lead to a loss of confidence and trust in our leaders. As demonstrated above, Serotonin strengthens the social contract between a leader and their team. We have no issues with our leaders getting the bigger office or more pay. In fact, the promise of a repeat of another Serotonin rush from a team win, means that most followers voluntarily give their leaders the best of whats on offer and some special treatment too. This is not on the basis of teams believing the leader is necessarily better than the group, but on the premise that the team believes that the leader is there to shield them from danger. Serotonin (and the confidence boost it gives) drives good leaders to run towards danger in order to protect the team. The group invariably grows to believe that they are all in it together and are looking out for each other with the leader at the helm.

Saber: Fight or Flight

However, when this social contract is broken – when the person we believe to be our leader sacrifices our safety for their own gain or we feel they have failed to protect us, then this trust is lost. The result of this is a new focus on self preservation. With the trust broken, individuals feel unsafe, they stop going that extra mile to get another Serotonin boost and connections weaken. At the same time, another chemical kicks in and initiates the fight or flight response.

That other chemical is Cortisol – the stress chemical which has preserved our species from the stone age till now and probably for centuries to come. Simon makes the important point that humans have not outlived dinosaurs or the saber tooth tiger because we are stronger or smarter but because we protected each other by working in groups and knew when to fight and when to run. Cortisol is great if there is an imminent threat as it helps us run or fight the danger. As part of our response to danger, Cortisol shuts down systems that are unnecessary for fighting or running e.g. our immune system and the system responsible for growth. This enables our body to focus on fighting or running. Once the danger passes, our Cortisol levels should subside.

However, in organisations and teams where the trust is broken and staff feel unprotected, levels of stress and Cortisol remain high. This means that our capacity for growth and immunity remain low. The result is what we see in teams with people who can’t seem to take anything in or learn anything new. This goes hand in hand with plummeting performance and a rise in sickness. It is not by coincidence that this happens, it is an indication that the environment has become too consistently stressful with no reprieve and no chance for Serotonin or indeed Dopamine to rebalance the trend.

Doing Good & Physical Connection Boosts Morale

But fear not, this gloomy set of circumstance can be turned around with good leadership involving yet another chemical. Oxytocin is the chemical of love. It is a feel good hormone resulting from human physical contact and connection. It makes us feel safe, valued and loved. We can get a rush of oxytocin from touch – something that explains the feeling of trust we get when we shake hands on a decision and get nervous if someone refuses to shake hands, or from simply sitting together and feeling like we are near someone who gets us.

We can also get a dose of oxytocin from doing good deeds. However, trying to game the system by simply giving money to charity or doing something that takes little time and effort doesn’t work. We don’t get the same rush of oxytocin if we try to game this system and it doesn’t feel as good. This is because the money we give is replaceable. But if we spend time – something we will never get back – then we and the person on the receiving end of that time and effort get that warm good feeling as Oxytocin is released.

The above applies to all organisations – simply telling a member of staff that you will pay money to solve a problem doesn’t make them feel valued. Responding to a call of help or distress with an e-mail saying ‘I care’ doesn’t make the recipient feel valued. However, picking up the phone or walking to that member of staff to ask ‘How can I help you?’ makes them feel valued. This is why I am a firm believer that walking the floor can never be underestimated – it puts the leader in and amongst the team and releases oxytocin – making both the leader and the team feel good. As it turns out, over time, the build-up of Oxytocin in our body protects against Dopamine addiction and improves immunity too so it’s a win-win in my humble opinion.

Summary

So what is the above trying to tell us about leadership? The messages I personally take away are:

Leadership is a personal choice made by those who want to improve things around them for the benefit of others -regardless of rank or position;

Teams and leaders do not excel in a system which relies solely on targets to drive improvement;

Serotonin is the Leadership chemical which primes us to repeat success by using public acknowledgement of achievements to share the sense of pride and build stronger bonds with our teams;

Leadership is rewarding but very challenging. Good leaders know that the perks come with many sacrifices. Those who put self-interest before the team and fail to protect their teams from harm lose trust and invariably promote an environment of stress and fear.

To drive performance and excellence, leaders need to remember oxytocin and be present with their teams. Take that extra effort to pick up the phone or walk the floor to build/re-build trust and promote the feelings of safety so that people can re-focus on doing their work.

So a big thank you to Sarah for sharing this insight. Interesting in the opening personal perspective and thought-provoking in the use of chemical drivers as a core medium.

...it can take a company years to build and it can be destroyed in moments

Chris MacDonald Business Ethics Blog @Canadian Business - "Valeant Pharmaceuticals has suffered a crisis of trust over the last few weeks. More specifically, the trust that investors had in the company was substantially diminished in the wake of revelations that Valeant had an unclear but apparently too-cozy relationship with specialty pharmacy called Philidor. The loss in trust in this case was quite concrete, measured by a substantial drop in the company’s share price.

The source of this loss of trust was, as is generally the case, a question about the company’s ethics.

Doing business in the long run absolutely requires ethics. At the very least, doing business requires a degree of mutual respect, embodied in our commitment to getting things from others by offering them what we think they want in return. It also requires a commitment to basic honesty, and a commitment to honour our contracts. These ethical basics are essential because they are the foundation of trust. And if you don’t trust someone—at some level—you’re just not going to do business with them.

If trust enables business, then trust has a real value, in real dollars and cents. So what, then, is the dollar value of trust? I estimate the dollar value of trust, within the global economy, at roughly $102 trillion—in other words, the entire nominal Gross World Product for 2014. Without trust, all commerce on the planet would literally grind to a halt.

The fact that trust is crucial in markets is evidenced by the fact that businesses have come up with such a dizzying array of mechanisms designed to generate trust—everything from brands (which carry reputations) through to warranties, return policies, endorsements and third-party guarantors.

But what exactly is trust? What does it mean to trust someone? Functionally, it’s an expectation that someone will behave in certain ways. Trust is also an attitude—part calculation, part emotion—that involves an expectation of goodwill, or at least good behaviour. It is an expectation that the other party to a transaction will not do us harm. As my friend and fellow philosopher Daryl Koehn once put it, trust is a mean between paranoia and foolish faith.

But what happens when trust is broken? How can a company like Valeant (or Volkswagen, for that matter) regain the trust of consumers and the investing public? There are many ways to rebuild trust, and none of them is quick.

A company that has lost the trust of the investing public is likely going to need to show a consistent pattern of trustworthy behaviour over a substantial period of time. And the focus, here, is on the showing. CEO Michael Pearson has said how important ethics is to the company. And—present appearances aside—that may well be true. But in the light of the current wave of mistrust, the company is going to need to do more. It is going to need to engage in substantial disclosures, far beyond detailing the nature of its relationship with Philidor. In the face of a failure of disclosure, the company may well find that that it needs to engage in more disclosure than any company—even one with nothing to hide—would be fully comfortable with."

The question is, how do organisations diagnose where it has gone wrong in the first place and have specific insights into how the organisation and individuals within them feel.

Changes conjure up many feelings and emotions - excitement, anticipation and happiness, but change can often herald reservation, concern, even fear.

While many leaders extol the benefits of change, not everyone shares that enthusiasm.

A client outlined the challenge he saw in taking on his new role as CEO. This challenge revolved around the level of fear he sensed throughout his new organisation. Phrases like "I can see the fear in their eyes" and "deep reservations about the future ahead" were quoted. There will be many reasons for these behaviours a nd this leader faced them as his prime challenge. Without commitment to the journey of necessary change throughout the organisation, he was "on a hiding to nothing".

Poor leadership can give rise to fear. Leaders define, affect and influence the culture of an organisation way beyond their own imagination. Some have no idea of the level of influence their behaviour has on others, not only on their direct reports, but through them on the whole organisation.

Resistance to change can also be due to;

Vested interests and personal fiefdoms which work hard to prevent change.

Potential organisational blindness to how the outside world really works.

Or, team spirit lost in transition.

Every organisation must evolve, adapt and remain sensitive to changes in its industry and others which can undermine what was once a stable and sustainable market. Often leaders read the situation correctly, but then act to bring about change in a way that destroys the very foundations that brought success to the organisation and would have served it well into the future, if only channelled correctly.So, back to my client. What could he have done? In this instance it was a case of acknowledgement. Acknowledgement of what has passed, how his predecessor in attempting to do the right thing – did wrong. Not wrong in realising that change was necessary, but rather in misunderstanding how to deliver change.

History plays a part in defining the behaviours of an organisation "the way we do things around here", and some recognised capability for change. The very success built into the DNA of the organisation that brought it to the current position, that same DNA would if handled correctly, deliver future success in the 'brave new world'. Listening to those who have seen the journey to this point and asking them the right questions such as "What have you learnt when facing this or that challenge in the past"? and "Which solutions worked, which didn't and why was this the case"? Getting under the skin of the what, why and how the organisation responds to the new, what constitutes the resilience amongst the teams and capability to adapt, change and renew - this is key.

Having listened, questioned and understood, it is as vital to acknowledge that history - the strength that has helped so far - and open the dialogue about what the future holds, what part each person thinks they can play and what do they see as the evolution necessary to meet the future.

None of this should detract from the crucial role any leader plays in doing his or her own strategic thinking, market analysis and all the other critical 'outward looking' actions. The real talent comes in performing the merger of listening and acknowledging within, with diagnosing and refining the challenges and opportunities without. This results in change for good, lessening the fear.

Fundamental to overcoming resistance to change is the building of trust. We can help with this. Contact – peter.buckley@buckley-partnership.co.uk

I remember when the Bee Gees released the song "Jive talkin'" in 1975. Oh those halcyon days as a teenager with no cares in the world, enjoying school (I actually really did!), and that enjoyment in life extended to most things including sports and playing football that summer in the streets of north London where I lived. Good times indeed. Truth is that at that time I didn't realise what the words really meant to the song, but sensed it was something about double talking and being misunderstood.

Anyway, it was only the other day while working with a client I asked a question to explore further with her why an excellent initiative to bring about innovative solutions to enhance business performance and productivity had floundered. It transpired she had taken the lead in offering to co-ordinate the work we had begun with her team and draw together their support – offered publicly at the time – to return to a final event and share the outcomes. Sadly she announced the initiative had not delivered as expected, although on the original day everyone was both enthused and enjoyed the work. Indeed, they came up with many robust ideas and potential ways of delivering the solutions, but when it came to working with her to bring them into practice she found everyone had a reason not to either reply, commit or even take their level of responsibility, declaring in most instances that they were either too busy or felt their personal priorities took precedence.While this short synopsis spares any further details to save exposing anyone, it is fair to say these sorts of outcomes are not uncommon. Why do so many initiatives, plans and stated actions, whether around cost-savings, increased productivity or simply improved customer service, flounder?

What is it about making promises when the spirits are high only to back down, finding excuses or simply avoiding doing what we said we would do? It all sounds like "Jive talkin'" to me.Truth is it doesn't have to be that way. By developing real trust within a team through open dialogue, conversations and discussions that really say what we think and think what we say, followed by doing what we say, consistently, things can be different, promises fulfilled and success achieved beyond the norm. All these simple, yet necessary actions will fundamentally serve as the true building blocks to sustainable trust in relationships, teams and organisations.

Have you had similar experiences? What worked and what actions complement the fundamental principle of trust?

While the whole area of codes and maxims in ethics is fraught with difficulty and interpretation, it is refreshing to think students today debate the same issues and come up with some really refreshing insights.

Below and some insight into ideas and thoughts collated by John Paul Rollert from Harvard students – I found them to be both profound and sound. Indeed, very thought provoking. I hope you feel the same.

Help others without hurting their sense of dignity

An ethical workplace is one where employees help each other. But as anyone who has ever had an overbearing boss can attest, no matter how good the intention, such offers can sometimes seem patronizing. Respecting individuals sense of independence will make the members of any team more likely to ask for, and accept help, especially when they face difficult moral decisions.

Self-control is not at odds with ambition

..it is essential to it. "Ambition is to be admired," It is a driving force behind capitalism, yet there are certain "boundaries that shouldn't be crossed." Pure ambition is not synonymous with personal success so much as with ruthlessness. To be successful, one's personal ambition must ultimately be guided by self-control and an eye toward broader social benefit.

Business may lionize individual achievement

...but responsibility to others is key. "No one person, no matter how ambitious or creative, can exist in isolation or complete independence from others". This is particularly true "in a technologically and economically complex society." The liberties we enjoy in a free society allow us to pursue our personal interests, but they are not without responsibility. One needs to balance them with the outcomes they produce, "lest someone else does the balancing for you."

Your gut is a great moral philosopher.

The feeling one gets in your gut when confronted with a moral conundrum not only precedes reasoned conclusions, it often indicates the best possible decision. "In the end, we have to be satisfied with what we do and not be forced to do certain things to please others". The mind can provide an excuse to do just about anything, but "the actual feeling that one gets when taking action" is not only morally reliable, it is not easily overruled.

A strong supporter of this perspective can be found in the father of the free market, Adam Smith. For him, morality was not some obscure science. Whenever someone tried to convince us of a moral matter, they aimed "to give an account, not only of the affairs of the very parish that we live in, but of our own domestic concerns." Certainly, we could reason away the wise counsel of the heart — human beings, Smith believed, were very skilled at making the expedient appear the just — but if we listened to the voice of our best instincts, our own and those of other people, we would rarely be led astray.

Direct contact with someone may not be as important in judging trustworthiness as was previously believed.

What made people trust Bernard Madoff? In the largest Ponzi scheme on record, thousands of investors in Madoff's funds lost billions of dollars. The fact that many of Madoff's friends and family members were among the investors may have helped him build trust with strangers, according to a recently published paper1, which finds that people can be won over by the names of someone's associates and the company he or she keeps.

This study's conclusions break with previous research on trust, which has identified the importance of incremental, evaluative processes — from snap judgments to relying on stereotypes to careful scrutiny — in forming initial impressions of someone. This paper finds that trust development can begin even before people meet or learn about one another's professional reputation or social status. Indeed, people can start trusting someone before they even realize it. To some degree, at least, the placing of trust is not the result of a deliberate assessment, the researchers say, but of subconscious cues.

In a series of three experiments involving more than 250 students, the researchers created a scenario similar to investment schemes — with the potential to either turn a profit or lose everything. The participants were first asked to list people they trusted or didn't trust and the reasons for their feelings. The researchers then primed the participants by flashing in their peripheral vision the names of those trusted or un-trusted associates, targeting an area of the brain that has been shown to process content without conscious awareness.

The students were then given US$5. They could send any portion of it, or none of it, to a stranger. They were told their "receiver" would get triple the amount they actually sent and would then decide how much of this profit to return. As with an investment scheme, the act of contributing money was risky but had the potential for shared gain. By measuring how much participants decided to invest after being primed either positively or negatively, the researchers found that people tended to send more money when influenced by the names of people they trusted. When asked to differentiate between people they liked and people they trusted, participants sent more money when primed by the names of those they trusted, suggesting that getting something back in return was an important factor in the trust-investment relationship.

In Madoff's case, victims may have subconsciously come to trust him because the names of his other investors — whether friends and family members or celebrities — encouraged them to believe in him as well. This conclusion is a warning to consumers and executives, who often search for recognizable names on client lists or professional associations when evaluating a potential partner or someone to do business with.

The researchers also point out that the changing nature of business, with increasingly fast-moving communications and travel, means that executives often have to build trust quickly among new co-workers and ever-forming teams. Given the importance of trust to organizational performance, the authors advise companies to employ visual cues — for example, project-related artwork or group photos — that might prompt thoughts of successful past relationships. Company events that bring potential partners together are also particularly useful, the paper concludes, because they form the basis of future name recognition and trust development.

Summary:

Deciding whether to trust someone, especially with your money, all too often is a matter not of slow, deliberate evaluation but of subconscious impulse. Name recognition plays a vital role; people can form impressions of others before they even meet, based on the new person's associates and the company he or she keeps.

On reflection this all makes sense. Our gut reactions play such a vital role in judgement and mindful of the influence of the basal ganglia (risk) and amygdale (fear) have in our decision making process, these findings corroborate the importance of knowing how you think and make decisions, especially when it comes to trusting others.

It is a well known fact, and published extensively in both braodsheets and business books, that strong, successful organisations, businesses and companies, be they in the commercial, public or not-for-profit sector, have the unerring ability to face into and confront the facts of the times.

As we stand here today in the passing long tail of an economic downturn which began in late 2008, times are tough. Work is tough, pressures are higher than ever, employment is a precisous commodity and success hard to maintain – for all of us things are different.

In a recent artilce published by Accenture (Outlook 2011:1) findings from thier reseach show compaines reporting that substantial portions of thier leadership and workforces lack resiliance and the ability to manage change.

The reality is, that finding talent is difficult and the emphasis is now on maintaining, nurturing and growing talent from within, and in this area lessons and solutions often should come from within. The 'great' companies and leaders know this and execute robustly.

So what pointers are there to leading service success?

In tough times the overall top level approach changes from 'growth' to 'harvest' through an appreciation of, and actions to adddress, some core tactics, namely;

Customers / clients want efficiency and saving (VFM)

Add to your core USPs – differentiate all the more

Optimise the technology you have

Whatever your offerings – the key is value (For clients as well as the business)

Marketing focused on current clients

Growth through existing clients – personalise.

Ultimately the goal is (in the eyes of your client or customer) a more personal, satisfying and richer customer experience than anyone else can do in your field.

Even with limited resources to target this, you can still prioritse when and how thus ensuring the successes demonstrate your focused approach and cost savings are achieved.

For those that love metrics and indicators, clearly they must be focused on leading indicators (predictors of change in behaviour) of the customer and their experience of you (If any readers are interested – let me know).

Of course these are all nice words in theory, but what makes the real difference is the whole issue of trust.

Trust as many readers will know from my previous blogs, is founded on consistent repeated actions underpinned by sound moral and ethical values.

How would you define your ‘middle space’? As a space where personal and interpersonal issues collide with business realities? But, does this interface work? How can we make our organisations tessellate with employees and clients alike? It’s in the DNA.

Reputation can be built and maintained in many ways, but how do you manage what people are saying about you? And is it helping or hindering the public image of your business?

You hope that people speak well of the care and service your practice provides. When that happens, patients choose you because what they've heard is all they need to know to believe that you are the right physician for them. When patients select you on the basis of word of mouth referrals, they are more likely to be satisfied because they know what to expect.There are four layers of word of mouth sources: Patients themselves, your staff, people who are trusted community members, including those who work in health care settings, and the community at large. ,br /> Patients - According to Michael Cafferky, author of Patients Build Your Practice: Word of Mouth Marketing for Healthcare Practitioners, a patient is most likely to tell other people about you in the first fourteen days after a visit with you. Communicating with your patient during that time increases the odds that they will tell others about you. Your Staff Members - "My doctor's very good, his secretary said so," a woman replied when asked about her physician. The most effective word of mouth commentary is what your staff has to say about your practice. After all, staff members know the inside story. Do your staff members understand how important they are in creating positive impressions about the practice? You have less to fear from your competitors than from indifference or negativity on the part of members of your own practice. Listen and respond to employee shop talk. In addition to creating a discouraging atmosphere, it's very upsetting to patients who hear or overhear negative comments.

What are the stories that you and your staff tell others about your practice? Stories help people make connections because people remember stories much more easily than a list of facts. When you are hosting a holiday, retirement or other party, listen carefully to the stories that are told and re-told. If the majority speak to mistakes, incompetence or conflict, it's time for you to tell a few stories of your own about positive differences staff members have made in the lives of your patients. Begin every staff meeting by mentioning a positive patient comment. Some practices encourage such feedback by keeping an album of patient letters in their reception area. It takes some maturity and experience in several different work settings before some employees realize that every organization has some faults. So, if a few younger employees are not referring new patients to you, they probably haven't thought much about it or don't know what to say. However, if the majority of your employees are not recommending new patients, something is wrong. There is most likely a quality issue that you haven't faced up to and/or remedied. Employees want to be proud of their organization and if they have concerns, they will be reluctant to invite their friends and associates to become patients.

Trusted Community Members - Each community has informal referral sources, such as local clergy, realtors, newcomers groups, lawyers, community leaders, fire and police officers and people who supply medical products or services. These individuals often have larger spheres of influence than other people. Nurses and pharmacists are highly trusted sources of information, but almost anyone working in a health care setting has frequent opportunities to make word of mouth comments. Advise your staff that you expect them to be particularly gracious with central schedulers at your hospital, for those folks will judge your practice by the behaviors and attitudes of every one on your team.

Establish relationships with staff members of physicians who refer patients to you. Acknowledge them by name when you call and thank them for any referrals that are made. Consider this scenario: A prospective patient asks the receptionist at his primary care office, "Dr. Jones gave me the names of two specialists. Do you know either of them?" The receptionist responds, "Well, I don't know Dr. Johnson, but Dr. Lowe over on Maple Street is very nice." Which physician is the patient likely to choose? The community at large - The more information patients have about you, the more likely they are to be satisfied with their experience. Dr. Joseph Wassersug, a retired internist living in Boca Raton, Florida, refers to this concept as the "recognition factor." When a new patient says "I know you, you're the doctor who..." the patient is more receptive to you. If they've heard of you, they think you're good. An Agency for Health Care Policy and Research study found that three out of four respondents would prefer a surgeon they were acquainted with to an unfamiliar one, even if the unfamiliar physician had a higher rating of some kind. Wassersug advises working with your hospital marketing department, writing a book, article or letter to the editor and being involved with the community as strategies to increase awareness about you and your practice.